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New approaches for evaluation and treatment of
appendicitis
Loren Berman MD
Pediatric surgeon Nemours-AI DuPont Hospital for Children
ACOP meeting 2017
Disclosures
I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) andor provider(s) of commercial services discussed in this CME activity
I do not intend to discuss an unapprovedinvestigative use of a commercial productdevice in my presentation
Appendicitis scope of the disease
Over 70000 cases annually in children in USA
Lifetime risk of appendicitis 9 for boys 7 for girls
Peak incidence 12 to 18 years
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Hospital-Acquired Infection
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Cost Variation
Objectives
Why do children get appendicitis
What are typical presenting features
How do we make the diagnosis
How do we decide WHETHER to operate
How do we decide WHEN to operate
What is the difference in how we approach perforated vs non-perforated appendicitis
Does every child with appendicitis actually need surgery
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Disclosures
I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) andor provider(s) of commercial services discussed in this CME activity
I do not intend to discuss an unapprovedinvestigative use of a commercial productdevice in my presentation
Appendicitis scope of the disease
Over 70000 cases annually in children in USA
Lifetime risk of appendicitis 9 for boys 7 for girls
Peak incidence 12 to 18 years
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Hospital-Acquired Infection
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Cost Variation
Objectives
Why do children get appendicitis
What are typical presenting features
How do we make the diagnosis
How do we decide WHETHER to operate
How do we decide WHEN to operate
What is the difference in how we approach perforated vs non-perforated appendicitis
Does every child with appendicitis actually need surgery
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Appendicitis scope of the disease
Over 70000 cases annually in children in USA
Lifetime risk of appendicitis 9 for boys 7 for girls
Peak incidence 12 to 18 years
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Hospital-Acquired Infection
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Cost Variation
Objectives
Why do children get appendicitis
What are typical presenting features
How do we make the diagnosis
How do we decide WHETHER to operate
How do we decide WHEN to operate
What is the difference in how we approach perforated vs non-perforated appendicitis
Does every child with appendicitis actually need surgery
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Hospital-Acquired Infection
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Cost Variation
Objectives
Why do children get appendicitis
What are typical presenting features
How do we make the diagnosis
How do we decide WHETHER to operate
How do we decide WHEN to operate
What is the difference in how we approach perforated vs non-perforated appendicitis
Does every child with appendicitis actually need surgery
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Journal of Pediatric Surgery 2017 52 669-676DOI (101016jjpedsurg201701013)
Copyright copy 2017 Elsevier Inc Terms and Conditions
Burden of Appendectomy Cost Variation
Objectives
Why do children get appendicitis
What are typical presenting features
How do we make the diagnosis
How do we decide WHETHER to operate
How do we decide WHEN to operate
What is the difference in how we approach perforated vs non-perforated appendicitis
Does every child with appendicitis actually need surgery
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Objectives
Why do children get appendicitis
What are typical presenting features
How do we make the diagnosis
How do we decide WHETHER to operate
How do we decide WHEN to operate
What is the difference in how we approach perforated vs non-perforated appendicitis
Does every child with appendicitis actually need surgery
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Why does appendicitis occur
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Who is more likely to present with perforated
appendicitis
A Younger patients
B Patients with developmental delay
C Uninsured patients
D Minorities
E All of the above
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
More likely to present with perforated appendicitis
Perforation rates are reported from 20-80 in children
Younger kids
ndash 82 in children under 5
ndash Nearly 100 of 1-year-olds
Developmental delay
Uninsured
Minorities
Kokoska ER1 Bird TM Robbins JM Smith SD Corsi JM Campbell BT Racial disparities
in the management of pediatric appendicitis J Surg Res 2007 Jan137(1)83-8
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Which of the following symptoms is LEAST likely to
be consistent with appendicitis
A Fever
B Nauseavomiting
C Diarrhea
D Peri-umbilical pain
E Anorexia
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
How do children present with appendicitis
Pain starts peri-umbilical and then migrates to RLQ
Pain starts insidiously is persistent and worsens over time
Pain is worse with movement
Fever nausea with or without vomiting and anorexia
Features suggesting alternative diagnoses
ndash Waxing and waning pain
ndash Diarrhea cough sore throat myalgias rhinorrhea and sick contacts
ndash (BUT there are patients with many of the above symptoms who DO have appendicitis)
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Differential diagnosis
Virus
Pneumonia
Constipation
In adolescent females
ndash PID
ndash Ovarian cyst
ndash Mittelschmertz
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Approach to physical exam in suspected appendicitis
Child does NOT want to move around
Focal tenderness
Percussion of the abdomen causes discomfort (this is better than rebound tenderness)
Psoas obturator Rovsingrsquos heel strike
Watch them walk around
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
ldquoDoes this child have appendicitisrdquo Meta-Analysis
Fever
ndash If present LR 34 (24-48)
ndash If absent LR 032 (016-064)
Rebound tenderness
ndash If present LR 30 (23-39)
ndash If absent LR 028 (014-055)
Migration of pain LR range 19-31
RLQ pain LR 12 (10-15)
WBC less than 10 LR 022 (017-030)
ANC less than 6750 LR 006 (003-016) Bundy DG Byerley JS Liles EA Perrin EM Katznelson J Rice HE
Does this child have appendicitis JAMA 2007 Jul 25298(4)438-51
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Alvarado A (1986) A practical score for the early diagnosis
of acute appendicitis Ann Emerg Med 15557ndash564
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
You are seeing a child in your office with 1-day history of
RLQ pain You are suspicious for appendicitis Where would
you send the patient
A Emergency room
B Same day outpatient surgery clinic
C CT scan
D Ultrasound
E Other
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
What to do with suspected appendicitis
Obtain imaging vs send to ED
ndash If any suspicion for viral syndrome with dehydration to ED
ndash If VERY HIGH suspicion for appendicitis and good pediatric radiologist is available consider sending child for ultrasound
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Operating Room
further wu per surgeon
Further workup and imaging in
consultation with
Surgery team
1 IV placed 20 cckg bolus CBC
2 Surgical consult within one hour
Strong suspicion on
HPE Equivocal history
physical exam
1 IV placed 20 cckg bolus CBC
2 Re-examine surgical consult within one
hour if still tender
Abdominal pain
ro appendicitis
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
What is the best way to image the appendix
A CT scan
B Ultrasound
C MRI
D Abdominal X ray
E Other
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Ultrasound
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
CT scan
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
MRI
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Summary of approach to imaging
Ultrasound is good if you have a high pretest probability good radiologist thin patient
MRI is good if you are in a center that uses it routinely to evaluate children with appendicitis
CT scan is best if above criteria are not met
Alternative to imaging
ndash OBSERVATION
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation if above management fails
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
When should appendectomy be performed in a
patient with non-ruptured acute appendicitis
A Immediately after diagnosis
B Within first 24 hours of hospital stay once appropriate antibiotics and IVF resuscitation have been provided
C After completion of a one-week course of antibiotics
D It is reasonable to treat these patients with antibiotics alone and not perform an appendectomy
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Is the appendix a ticking time bomb
Traditional teaching appendicitis is an emergency and should be treated with surgery immediately upon diagnosis
Several studies have now shown that delays of 12 hours up to 48 hours do not increase risk of perforation
Current standard admit IVF resuscitation antibiotics appendectomy during daylight hours
Almstroumlm M1 Svensson JF Patkova B Svenningsson A Wester TAnn Surg 2016 Mar 8 In-hospital
Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children A Single-center
Retrospective Cohort Study
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Port placement
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Lap appy with Endo-loops
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Lap appy with stapler
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Open appendectomy
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Appendix with fecalith
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Laparoscopic vs open appendectomy
Laparoscopy is standard of care
Lower complication rate
Less scar
Less pain
Ability to evaluate other intra-abdominal organs if the appendix looks normal
ndash Gallbladder
ndash Ovaries
ndash Inguinal canal
Sauerland S Jaschinski T Neugebauer EA Laparoscopic versus open surgery for
suspected appendicitis Cochrane Database Syst Rev 2010 Oct 6(10)
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Post-op course
Most patients can go home on the day of surgery
Recovery is usually quick
Back to school within a week sports within 2 weeks
Very low risk surgery with good outcomes
Risk of infection is about 5 at port sites or in abdomen
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
You see a 7 year old male in your office with 1-day history of abdominal pain
now localized to RLQ with focal guarding and poor appetite You send him for
ultrasound and it shows appendicitis His mother has heard about some new
research and wants to know if you would recommend just treating with
antibiotics rather than surgery How would you counsel this mom
A This data is preliminary and surgery is still standard of
care
B This may be a reasonable option for her son and she
should discuss it with her surgeon
C If it were your son you wouldnrsquot let him have surgery
D Other
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Do all patients with appendicitis require surgery
Pilot study at Nationwide Childrenrsquos Hospital
102 patients
ndash 7 to 17 years of age
ndash Uncomplicated appendicitis defined by
Abdominal pain le 48 hours
White blood cell count le 18000
Ultrasound or CT scan showing appendicitis with an appendix le 11 centimeter thick and no
evidence of abscess or fecalith
Patients and families chose to have appendectomy or antibiotics alone
Non-operative management at least 24 hours of in-hospital observation and IV antibiotics until symptoms improved followed by completion of 10 days of treatment with antibiotics by mouth
Minneci PC Mahida JB et al The effectiveness of patient choice in non-operative
versus surgical management of uncomplicated acute appendicitis JAMA Surgery
2015 Dec 16
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Results of non-operative management
65 families chose appendectomy 37 families chose non-operative management
Success rate of non-operative management (defined as not undergoing an appendectomy) 89 at 30 days 76 at 1 year
The 24 who failed did NOT have a higher rate of ruptured appendicitis compared to the patients who had immediate appendectomy
1 year follow-up the children managed non-operatively compared with the surgery group had fewer disability days (8 vs 21 days) lower appendicitis-related health care costs (median $4219 vs $5029) and no difference in health-related quality of life
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Non-Operative Treatment of Appendicitis Rationale
Appendectomy is invasive
Children may miss up to two weeks of schoolactivities
Caregivers miss work
Postop complications after appendectomy for uncomplicated appendicitis 5-10
Serious complications (reoperations or readmissions) 1-7
Adult data suggest one-year success rates of 63-85 no difference in rates of complicated appendicitis
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
bull Meta-analysis of 10 articles reporting 413 children receiving non
operative treatment (NOT) for appendicitis ndash all published in past 10
years
bull 5 comparative
bull 1 RCT
bull 4 case series of NOT
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Interpreting meta-analyses Forest plot
Favors
antibiotics
Favors
appendectomy
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Overall success of NOT
97 during initial episode
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Incidence of recurrent appendicitis during follow-up period (range 2-51
months)
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Long term efficacy of NOT (no appendectomy at end of follow-up
period)
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
LOS shortened by about 05 days in those undergoing appendectomy
compared to NOT
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Increased rate of complications for appendectomy compared to NOT
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Authorsrsquo Conclusions
ldquoCurrent data suggest that NOT is safe It appears effective as initial treatment in 97 of children with AUA and the rate of recurrent appendicitis is 14rdquo
The study highlights the lack of robust evidence comparing NOT with appendectomy in children
Confirms a position of equipoise between treatment approaches
We recommend that NOT of children with AUA be reserved for those participating in carefully designed research studies
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Take-home point
Lap appy is still standard of care for uncomplicated appendicitis
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Once diagnosis of appendicitis has been establishedhellip
Non-ruptured
ndash Short duration of symptoms no suggestion of rupture on imaging
ndash Start antibiotics
ndash Perform appendectomy
Ruptured
ndash Have radiology evaluate for drainable fluid collection
ndash Antibiotics
ndash Operation in acute setting if above management fails
ndash Interval appendectomy 6-8 weeks laterhellip
ndash ALTERNATIVELY Just take out the appendix
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
CT ruptured appendix with abscess
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
After placement of percutaneous drain
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
How to counsel families of children with ruptured appendicitis
If kids tolerate a diet pain resolves fever resolves oral antibiotics and home
Plan interval appy 6-8 weeks later
Non-operative management may not work and surgery may be needed (Failure rate 20)
At home they should watch for signs of persistentrecurrent appendicitis
High-anxiety time for patients and families
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
A 10-year-old boy comes to see you in the office after recent
hospitalization for perforated appendicitis He has 3 more days of
antibiotics left His mom is worried because appetite is poor and his
energy level is low On exam he has diffuse lower abdominal
tenderness You recommend
A Extending course of oral antibiotics
B CT scan to evaluate for persistent or
recurrent appendicitis
C CT scan to evaluate for intra-abdominal
abscess
D Follow-up with surgeon
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Is interval appendectomy necessary
In adults many surgeons do not do this operation
In kids data are limited
ndash 2-year follow-up of 96 patients
ndash Perforated appendicitis treated non-operatively with antibiotics
ndash 6 became worse 41 had interval appendectomy
ndash 49 received no further treatment
ndash 57 no recurrence
ndash 43 had recurrence within one month to 2 years
ndash Presence of appendicolith 72 rate of recurrence vs 26 in those without appendicolith
Ein SH1 Langer JC Daneman A Nonoperative management of pediatric ruptured appendix
with inflammatory mass or abscess presence of an appendicolith predicts recurrent
appendicitis J Pediatr Surg 2005 Oct40(10)1612-5
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Approach to interval appendectomy
More strongly recommended if fecalith present
Observation is a reasonable option
Best choice for an individual patient depends on their anxiety and parental anxiety
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Immediate operation for ruptured appendicitis perhaps a better
option
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Meta-analysis operative vs non-operative management of pediatric
ruptured appendicitis
2 RCTs identified
Total of 171 pediatric patients
Compared early vs interval appendectomy
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Early appendectomy reduced incidence of adverse event
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Ruptured appendicitis may have abscess or phlegmon
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Early surgery was more strongly favored when there was no abscess at
time of presentation
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Decreased antibiotic duration length of stay and total charges for
abscess and no abscess groups
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
You are seeing a 7 year old with constipation A
fecalith was seen on abdominal X ray during recent
ED visit How would you counsel the family
A They should be referred to surgery for appendectomy
B Their child is at higher risk for appendicitis so they should be aware of this in case he develops symptoms
C It is uncertain whether this child is at higher risk for appendicitis
D A course of Miralax may help wash out the fecalith
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Take home points
Uncomplicated appendicitis
ndash Lap appy is still standard of care
ndash Non-operative management may be an acceptable option but not enough is known about long-term risk of recurrent appendicitis
Complicated appendicitis
ndash Can be managed with immediate operation delayed appendectomy or no appendectomy
ndash Immediate operation is probably more efficient and less stressful for patients and parents
Thank you very much
Questions
Thank you very much
Questions
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